AIC Referral Form

You may make a referral using the form below.

 

 Ambulatory Infusion Center

Referral Form

 

Patient Name:  __________________________________ DOB:  ______________

Allergies:  __________________________________________________________

Diagnosis:  _______________________________________ ICD10:  ___________

Home Health Agency involved:  ________________________________________

Therapy Requested:  

• Weekly dressing change with lab draws (please circle labs below) 

• Weekly dressing changes ONLY

• Labs ONLY (please circle)

 

CBC                                          Cr/BUN

BMP                                        CPK

CMP                                        Vancomycin trough

CRP                                         Other trough__________________________________

ESR                                         Other labs_____________________________________

• Results to be faxed to:  Provider______________ Fax #:  ______________

• First dose

 

**Please attach relevant cultures/pathology/labs/imaging/last progress note**

• Drug Name:  ______________________________________

• Dose:  ____________________________________________  Route: ____________

• Duration/EOT Date:  _________________________________

• Has the patient ever had this medication before?  YES NO. If yes, has the patient received the medication in the past three months?  YES NO. If yes, date of last administration:  __________________________________

 

 

Physician’s Signature __________________________ Date __________

Physician Name (print) _______________________________________

NPI: _______________________ Address:  ________________________________________